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Introduction
Up to 30% of patients with ulcerative colitis (UC), will require surgical management of their disease because of medically intractable disease, fulminant course, dysplasia or cancer and even due to patient preference not to take medication on an indefinite timeline. Before the 1980s surgical management typically involved a total proctocolectomy and permanent ileostomy. However, advances in surgical techniques led to the establishment of colectomy with ileal pouch-anal anastomosis (IPAA) as the standard operation of choice for most patients (see figure 1 ).
Patients with UC who have undergone IPAA are prone to develop inflammatory and non-inflammatory complications, which include early or late surgical complications (such as an anastomotic stricture or leaks, fistulae and pelvic abscess), cuffitis, irritable pouch syndrome and pouchitis. According to some series approximately 50% of patients can be expected to experience at least one episode of pouchitis (see figure 2 ). In a study of complications and long-term outcomes in 1310 patients who underwent IPAA for chronic UC, 559 patients had at least one episode of pouchitis. 1 The cumulative risk of having at least one episode was 18% at 1 year after surgery and 48% at 10 years. Approximately 394 of the 559 patients who had at least one attack of pouchitis had a second episode. The cumulative probability of having a second episode after an initial attack within 2 years of IPAA was 64%.
Patients with IPAA for UC tend to experience a variety of symptoms, ranging from mild pelvic or perianal discomfort to a debilitating complex of symptoms that may eventually lead to pouch excision thereby necessitating the construction of a permanent ileostomy. The most common complication of the ileal pouch, among patients with UC, is pouchitis, affecting up to 50% of patients. The specific aetiology of pouchitis is unknown and the method for diagnosis and classification of pouchitis is not completely agreed upon. Clinicians typically base their suspicion of pouchitis on a constellation of clinical symptoms such as: an increase in stool frequency, tenesmus, change in stool consistency, abdominal cramps and rectal bleeding. Treatment is often prescribed based on these clinical symptoms alone. However, diagnosis of pouchitis based on symptoms alone has been shown to be non-specific due to the fact that symptoms can originate from...